Preoperative Medical Assessment - Assignment Example

Preoperative Medical Assessment Description The incident occurred during my first clinical placement as advanced nursing practitioner (ANP) student in the pre-anesthesia clinic. I was assigned with anesthetist to evaluate the patient's physical condition, medical problems and review of diagnostic data before the procedure thus, optimizing patient healthcare. According to Hemanth Kumar et al. (2013), assessing and evaluating patients preoperatively is an important starting point to formulate an effective anesthetic plan. High rate patient turnover in the clinic, the preoperative assessment performed just prior to the scheduled surgery for patients admitted on the same day of operation, presenting with complex medical conditions, insufficient time for review of tests or reassessment after medical treatment can pose challenges in the healthcare. They are the leading cause of operation cancellation, an inefficient use of operating room time as well as wasting of resources (Hori, Nakayama & Sakamoto, 2016,). Mr. K was one of the outpatients canceled cases. He was a 65-year-old male who lived in the south of Saudi Arabia, scheduled for gallbladder removal; cholecystectomy due to the gallstones causing mild-moderate RUQ pain, infection and nausea. Mr. K came with past medical history of mitral valve replacement (MVR), asthma and uncontrolled type2 DM. Post 10 years’ cardiac catheterization was noted. Mr. K was confused and last work lap was done 1 year back and no recent echocardiogram (echo) done for the patient. Last random blood sugar test was 400 mmol/l. His son accompanies him and said he had been on the following medication; warfarin 5mg/day, steroid inhaler (fluticasone propionate 250 mcg/day) and metformin500mg PO BID. After completing a history and physical exam, the anesthetist and I concluded that Mr. K was not clear for surgery due to the following reasons; unstable blood sugar, chest is not clear; wheezing, no recent laboratory workup especially international normalized ratio (INR) testing and no echocardiogram (echo) was done to justify heart condition. Additionally, Mr. K was determined to be in Class 3 based on the American Society of Anesthesiologists' (ASA) classification of the physical status system. This indicates that patient can be at risk of surgical and anesthetic perioperative morbidity or mortality. Avidan and Weiniger (2018) defined the ASA classification of physical status as a system for assessing the fitness of patients before surgery.  Feelings/thought I was extremely displeased and on immediate panic when encountering resistance from Mr. K to accept the cancellation of scheduled surgery. Mr. K and his son were very disappointed with anesthetist decision as they had been waiting for the surgery long time, and had traveled outside of their city to do it. Arguably, a study by Bass and Gill (2014) concluded that elective surgery cancellations both increase patient anxiety as well as reduce patients’ confidence in their healthcare setting. However, I believed that it is important for the anesthetist to familiarize with the specific features of drugs needed for treatment as well as the unusual characteristics of the disease. Tobias (2018) identified that inadequate preoperative assessment of the patient can be a major contributory factor to the primary root cause of perioperative mortality. From ANP student point of view, I assumed that cancellation of scheduled surgery can cause both financial loss and emotional stress, which may impact on patients wellbeing. It also increases healthcare expenditures and creates significant inconvenience for patients and their families. Evaluation Dubé and Ducharme (2015) argue that to ensure proper professional development one needs to first identify positive experiences, challenges, limitations and personal strengths. In this regard, there are some positive aspects I identified during the encounter with Mr. K. Firstly, my interview with the patient offered the opportunity to practice the theories learned in the medical field. Secondly, the experience was able to reveal my enthusiastic and passionate characteristics and I was motivated to work independently. Again, as an RN the experience obtained from the encounter with my patient presented one of the serious challenges in my career which become an opportunity for me to begin building my knowledge and self-confidence. Khanade et al. (2017) claim that self- efficiency and self- confidence is important in the profession of nursing. The reason is that RNs mostly work under highly stressful conditions and are not required to hesitate in making complex decisions. The experience also allowed me to bridge the gap between practice and knowledge. Mainly, such an experience was important to increase my techniques and skills for interviewing future patients and obtaining their mindful clinical history. Another positive thing about my experience is that I have been stimulated into the application of effective clinical decision making and critical thinking. In this regard, I have been able to recognize the importance of prioritizing patients needs and identifying their desired levels of care. Victor-Chmil (2013) advocates for the proactive approaches of clinical judgment and critical thinking and clinical judgment since they are the evidence-based course of action. Mainly, this is important especially when determining a good clinical history and can result in safe and quality nursing care. Nevertheless, the case of preoperative assessment of Mr. K prompted doubts and debates about various important aspects of nursing for me. For example, I have realized that surgical cancellation due to the inadequate preparation patient before surgery, workload, lack of counseling and absence of advanced nursing practitioner role and specialist in the preoperative setting all have a negative impact on the hospital setting. The Australian Incident Monitoring Study database reveals that about 11 percent of reports indicated incorrect or inadequate preoperative assessment (Hemanth Kumar et al., 2013). Consequently, decreasing work productivity, quality of clinical history taking/examination, patients satisfaction toward healthcare and job satisfaction among clinicians. Undoubtedly, one of the main long-standing challenges in healthcare organizations globally has been the cancellations of planned surgical procedures They result in wastage of resources and revenue and have significant financial, social and psychological implications for families and patients (Bass and Gill, 2014; Tobias, 2018). According to the study, the studied general hospital indicated the cost of surgery cancelation to be considerably high. More than half of the cost (62.1%) of surgery cancelation was due to avoidable reasons (Bass and Gill, 2014). Therefore, I believed that preoperative ANPs have a positive impact to overcome such issues. Analysis The purpose of the preoperative assessment is to ensure that the patient is ready for the surgery and chances of survival and healing after the surgery is optimal. The experience with Mr. K has aided me to understand, prioritize, and look in-depth the list of skills/ characteristics needed as ANP. It also allowed me to critically think and grow in my area of expertise. Based on the perspective that Hori et al. (2016) give about what can cause preoperative surgery cancellation, Mr. K’s case that featured underlying uncontrolled diabetes, cardiovascular problem, and chest-related issues, as well as the ongoing anticoagulation medication with no updated lab result, was not an optimal condition for the surgery. I agree with Hemanth Kumar et al. (2013) that any preoperative evaluation requires history and physical examination that focuses on risk factors for pulmonary and cardiac complications to determine the functional capacity of a patient. Tobias (2018)declared that laboratory investigations must be ordered only once indicated by the patient’s medical condition, drug therapy as well as the nature of the proposed surgery and not on a routine basis. According to Melnyk et al., 2011the laboratory results obtained between 3 and 6 months are reliable unless the patient shows major abnormalities or there are changes in his or medical condition. This all was absent in Mr. K case which leads to canceling his case. As ANP student I believe that the preoperative assessment/preparation is a critical point of the care course as the patient transitions through the perioperative environment. The experience demonstrated the different roles and impacts that ANP has in the preoperative assessment, especially in an anesthesia clinical setting. According to Ezike et al. (2011), the purpose of the preoperative assessment is to ensure the patient is in an optimal state and ready for anesthesia and surgery. However, to establish this purport, an advanced level of nursing practice would be required in order to the preoperative state of the patient has a potentially positive influence on the surgery process and postoperative care and healing. Advanced nursing practice is required in the preoperative assessment in order to perform several pre-anesthetic assessments, determine how various factors impact the preoperative duration and assess medical history and their potential effect (Melnyk et al. 2011; Kumar & Gandhi 2012). Besides these roles and impacts, Woo et al. (2017) list keeping objectives for premedication in check, including possible amnesia, anxiety, and depression, among others, as an additional impact of ANP in the preoperative assessment in an anesthetic clinical setting. Conclusion Overall, the crucial goals of preoperative medical assessment are to minimize the patient’s surgical and anesthetic perioperative morbidity as well as mortality. It’s also to return patients to desirable functioning rapidly. The preoperative preparation is a core competency and responsibility for the multidisciplinary team. The case of Mr. K allowed me to critically reflect upon my personal experience as an ANP student, and identify my strengths which included my enthusiasm, ability to show compassion towards my patient and applying theoretical knowledge. Good preoperative preparation was a key missing component in the successful outcome of Mr. K case. In my opinion, well-mannered preoperative care improves and enhance the patient experience by minimizing anxiety as well as promoting recovery. I believed that determining the major avoidable contributors to day-of-surgery cancellations or prior is a fundamental step to developing appropriate interventions to advance/improve operating theater efficiency. While the surgery was meant to address a medical situation, it is also necessary to ensure that the patient is capable of surviving the surgery and healing effectively after the process, which Mr. K was not; the underlying medical issues, as well as the ongoing anticoagulants medications, made it impossible for the intended surgery. Moreover, I now understand that ANP is integral for a preoperative assessment, especially in an anesthetic clinical setting, since it optimizes the assessment process by ensuring that every factor is considered, every perspective is incorporated, and the outcome optimizes the chances of the patient. Action plan pre-anesthetic assessment continues to become more challenging with an increase in outpatient anesthesia where most patients report to hospitals shortly before engaging in a procedure. Canceling Mr. K's surgery was necessary to give time for an effective approach to his situation, which should include addressing the underlying medical problems first, but, it also offset unpleasant feelings that also needed an effective response. In order to overcome such a situation and all the preoperative related issues in future, ANPs can play a vital role to integrate and implement evidence-based action strategies. These strategies may include; Developing of an appropriate perioperative care plan for all procedures. Assessing the patient's overall health status enough time prior to surgery. obtaining preoperative education about surgery, anesthesia, intraoperative-care, and postoperative pain treatments, therefore, reducing anxiety and facilitating recovery. Adopting guidelines may help avoid “routine” preoperative testing and direct the preoperative evaluation using an evidence-based methodology. Read More